Newborn management during air transport

Air transport during the neonatal period requires a thorough assessment of the anatomical-functional characteristics of the developing organism, the environmental modifications associated with the pressurized cabin and the safety procedures provided for by civil aviation regulations. Atmospheric pressure changes occurring during the ascent and descent phases are the main factor responsible for flight-related otological discomfort, resulting from the difficulty in pressure compensation of the middle ear through the Eustachian tube, a structure characterized in the first months of life by morphological and functional immaturity.

The promotion of swallowing through breastfeeding or non-nutritive sucking promotes tubal opening and the rebalancing of pressure between the external environment and the tympanic cavity. A correct management of exposure to air conditioning, an adequate positioning of the parent, the use of certified restraint devices and knowledge of the procedures established for infants and children allow for optimizing safety and comfort during the journey.

Air travel in the first months of life constitutes a condition in which the neonatal organism is exposed to physical environmental modifications not present in daily home life. The environment of the aircraft cabin is characterized by atmospheric pressure reduced compared to sea level, a decrease in relative humidity and the presence of continuous ventilation systems. Adaptation to such conditions depends on the degree of maturation of the respiratory, immunological and otorhinolaryngological systems. Particular attention must be given to premature infants, subjects with cardiopulmonary pathologies, chronic respiratory alterations or recent upper respiratory tract infections.

 

Anatomy and physiology of the neonatal otorhinolaryngological system

The neonatal auditory system possesses different structural characteristics compared to adulthood that influence the ability to adapt to pressure variations. In particular:

• The outer ear includes the auricle, the external auditory canal and the tympanic membrane. In the newborn, the auditory canal has smaller dimensions and an anatomical configuration characterized by a different inclination compared to the adult. The tympanic membrane has a relatively more horizontal position and a different biomechanical elasticity, elements that can modify the response to pressure variations.
• The middle ear includes the tympanic cavity and the ossicular chain consisting of the malleus, incus and stapes. The function of the tympano-ossicular system depends on maintaining a pressure balance between the external environment and the cavity of the middle ear. A significant variation in this balance leads to changes in the tension of the tympanic membrane with the possible onset of pain.
• The Eustachian tube constitutes the anatomical connection between the nasopharynx and the middle ear and performs an essential function in ventilating the tympanic cavity, draining secretions and compensating for atmospheric pressure. In the newborn, the Eustachian tube has a reduced length, a more horizontal course and less rigidity of the cartilaginous structures. Furthermore, the muscles responsible for tubal opening have a functionality that is still in the developmental phase. This configuration results in greater difficulty in pressure compensation during rapid changes in the external environment.

 

Pressure changes during flight and auricular barotrauma

During takeoff, the internal pressure of the cabin progressively decreases, while during the landing phase, it increases rapidly until reaching the ambient pressure. The descent generally constitutes the moment of greatest stress on the middle ear, as it requires effective air entry through the Eustachian tube. When compensation does not occur adequately, a pressure difference is created between the tympanic cavity and the external environment. This condition causes deformation of the tympanic membrane, stimulation of sensory nerve fibers and the onset of painful symptoms.

In the newborn, discomfort can manifest through sudden crying, irritability, behavioral changes, reduced sucking or difficulty in relaxing. The risk increases in the presence of nasal congestion, rhinitis, upper respiratory tract infections or recent episodes of otitis media.

 

Role of sucking and breastfeeding in pressure compensation

The physiological “strategy” most commonly used to promote pressure adaptation consists of stimulating repeated swallowing. Sucking results in complex neuromuscular activation involving the jaw, pharyngeal muscles and structures responsible for opening the Eustachian tube. Breastfeeding during the takeoff and landing phases simultaneously promotes nutrition, neurovegetative regulation and frequent swallowing acts.

Also the use of a pacifier can promote the compensatory mechanism by stimulating swallowing. It is advisable to start sucking just before the pressure change and maintain it during the phase in which middle ear adaptation is most required, particularly during the final descent.

 

 

Influence of air conditioning on neonatal physiology

The cabin environment has reduced relative humidity and a temperature controlled by continuous air conditioning systems. The newborn possesses athermoregulatory capacity that is still immature and direct exposure to the cold air flow can result in irritation of the respiratory mucous membranes, increased nasal dryness and greater difficulty in tubal ventilation. It is therefore advisable to avoid the direct blast of air on the face, use layered clothing that can be adjusted and maintain regular feeding to ensure adequate hydration.

 

Parent positioning and seating organization

The positioning of the parent with the newborn must be planned considering the care needs during the flight. The front rows of the cabin or seats designed for the installation of the aircraft bassinet can offer more space and better management of the baby’s needs. Rows corresponding to emergency exits are generally not assigned to passengers with infants, as they require the ability to cooperate with the crew in emergency operating procedures.

 

Safety systems for infants and children up to 3 years old

For children under twenty-four months of age, airlines generally provide two modes of transport:

• On the parent’s lap, using a supplemental restraint system provided by the crew
• On an individual seat, using a certified device compatible with air transport.

The seat belt of the adult must not be used to directly restrain the infant, as this configuration does not guarantee an adequate distribution of forces in the event of turbulence or sudden deceleration.

After reaching two years of age, the child normally requires an individual seat and can use the aircraft seat belt or a certified restraint system according to the instructions of the airline and the manufacturer.

 

Italian and European regulations

In the context of European civil aviation, procedures regarding the transport of minors are defined according to safety standards coordinated by the European Union Aviation Safety Agency. The infant category generally includes children from zero up to twenty-three months of age. In this range, the child can travel without an individual seat according to the methods provided by the airline or with a dedicated seat using a certified device.

From the age of twenty-four months, the child is generally classified as a child passenger and requires an individual seat. The economic conditions relating to tickets, transport of the stroller, dedicated luggage and additional services depend on the commercial policy of the air carrier. A lightweight, compact stroller designed for travel may fall, depending on the model’s dimensions and the airline’s regulations, within the specifications provided for transport as carry-on luggage.

 

Conclusions 

The management of the newborn during air transport requires an approach based on the knowledge of various aspects. The difficulty of middle ear pressure compensation mainly stems from the immaturity of the Eustachian tube, a condition that makes the newborn more susceptible to discomfort during rapid changes in atmospheric pressure.

Breastfeeding, sucking and stimulation of swallowing constitute physiological tools aimed at promoting tubal opening and pressure rebalancing.

Proper preparation for the journey, associated with the appropriate choice of seat, protection from thermal exposure and the proper use of restraint systems, ensures safe conditions during air transport in the first years of life.